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161 Cards in this Set
- Front
- Back
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What portion of US pregnancies are unintended? Of those, how many end in termination?
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half unintended and half of those end in termination
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Who brought the diaphragm to the US from Europe in the 1920's?
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margaret sanger
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How should a diaphragm fit?
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Want the largest the vagina will accomodate without them feeling it
tucks behind symphasis to cover anterior vaginal wall, sizes 65-85 |
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What are the advantages and disadvantages of barrier methods?
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Advantages- may be used by women with many medical conditions, some are non-latex, don't have to be exposed to hormones
disadvantages- lower efficacy, local reactions to spermicides, may require an office visit, coitally dependent |
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How long does a sponge last?
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24 hrs and lots of sex
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Do you have to reapply spermicide with a femcap?
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no
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Spermicide might facilitate acquisition of?
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HIV
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What is the Lea's shield? who is it more effetive in?
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Non-latex cervical cap that comes in one size and is used with cervical cap. more effective in nulliparous women
Requires an office visit for fitting |
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What is the efficacy of lea's shield?
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Parous women- 60-74%
Nulliparous- 80-91% |
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When is lea's shield inserted? In place for how long?
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Can be inserted any time prior to intercourse, can be worn up to 48 hrs. Must use back-up while learning to use it
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What is a FemCap? Who is it more effective in?
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Non-latex cervical cap, flexible domed cap that covers the cervix. Underside covers cervix and brim forms seal agains vaginal wall, groove stores spermicide, comes in 3 sizes.
More effective in nulliparous women |
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when is the FemCap inserted?
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Can be inserted several hours before sex, can be worn for up to 48 hrs but must wear for 6-8 hrs after sex to allow spermicide to work?
needs an office visit to fit |
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What is the efficacy of the femcap?
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parous women- 60-74%
nulliparous woemn- 80-91% |
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What type of condom is best? What do they protect from?
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Latex, followed by polyurethane. Skin condoms might let virus through.
Good at preventing HIV, chlamydia, gonorrhea but not 100% against HSV and some others |
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All birth control pills are dominant in which hormone?
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progestin
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**What is the primary action of progestin in OCPs?
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**Suppresion of LH, thickening of cervical mucous, making the lining of the uterus atrophic, influence capacitation**
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What is capacitation?
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the ability of a sperm to penetrate an ovum
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**What does estrogen in OCPs do?**
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suppresses FSH, makes endometrium grow, cycle control
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What happens if just given progestin?
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bleed all the time
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If a women is on OCPs, what should her cervical mucous look like?
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Thick and tacky, question her if it is thin and stringy
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What are the pharmacologic effects of progestins in combination OCs?
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inhibit ovulation by suppressing HPO function, modify mid-cycle surges of LH/FSH, diminish ovarian hormone production, produce endometrial changes unfavorable for ovum implantation, thicken cervical mucus to impede sperm transit, inhibit sperm action
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What are the pharmacologic effects of estrogens in combination OCs?
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interferes with HPO pathway, suppression of LH/FSH, increased proliferation of endometrium, alteration of secretion from endometrium, alteration of endometrial cellular structure
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What are the major classes of synthetic progestins?
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19-norprogesterone
17 alpha-hydroxyprogesterone 19-nortestosterone spironalactone |
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What type of progestin might a woman have skin issues on?
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those that are more androgenic, so switch the type of progestin
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What are the major classes of synthetic estrogens?
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ethinyl estradiol, mestranol (converts to 50% ethinyl estradiol so need more of it)
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What has pill design in the last few years focused on?
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Reducing the dose of the estrogen and progestin components and new, more selective progestins. Goal for lowered doses is a pill that does not compromise bleeding profiles
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Why are all combo OCPs anti-androgenic in the way they behave?
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The oral estrogen increases the sex hormone binding globulin (SHBG) and this binds the testosterone that causes acne
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What is causing a breakout from the pill?
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the type of PROGESTIN, so change that to a less androgenic pill
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What is a low dose combo OCP? What happens as you lower the dose?
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35 or less estrogen
As go lower then destabilize the endometrium leading to weird bleeding. If odn't want nuisance bleeding then put on 35 |
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What are the non-contraceptive health benefits of combo OCPs?
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**Significant reduction in ovarian cancer**, reduction in endometrial cancers, dysmenorrhea, menorrhagia, menstrual cycle disorders, ectopic pregnancy, PID, iron deficiency anemia, benign breast disorders, acne
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What are the emerging benefits of combo hormonal methods?
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reduction in benign ovarian tumors, colorectal CA, perimenopausal symptoms, osteopenia and postmenopausal ostioporotic fractures, bacterial vaginosis
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**Who is NOT a candidate for combo pills?**
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over 35 and a smoker
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What are contraindications for combo hormonal methods?
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**migraine with aura** (potential for seizure)
out of control DM, HTN, thrombophlebitis, DVT history, CAD, valve problems, surgery with prolonged immobilization, carcinomas of breast or endometrium, abnormal genital bleeding, jaundice, pregnant |
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Why should you ask a woman about surgery's?
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don't give estrogen containing birth control if immobilized
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What are the relative contraindications for combo birth control?
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vascular migraine, HTN, recent hepatitis, DM, recent surgery, age 35 smoker, active gallbladder disease, completion of term pregnancy within 10-14 days
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Why should you take a pill break?
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no reason!
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Do OC's increase breast cancer risk?
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**No!!!**
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What are some estrogenic symptoms of OCP's?
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breast tenderness and nausea. Not uncommon in first few packs (tell people this). If cont. then lower estrogen
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What are progestin symptoms of combo OCPs?
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acne or moodiness, change the progestin
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How long should a woman try any pill for?
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3 months- if switch every month they will never get settled
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Why does extended use of hormonal contraceptives increase efficacy?
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First cycle after birth control is usually very fertile, so if miss that first pill of new pack you are risk for oculation- so decreasing number of periods increases efficacy
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What is the dominant hormone of OCPs?
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progestin***
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Why might heavy women bleed more heavily?
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b/c they are getting estrogen from fat as well
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What problems might be managed to with extended use of hormonal contraceptives?
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endometriosis, pain, bleeding, HA
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What is the pill of choice to continuous cycle?
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monophasic
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What are 2 meds that impact OCPs?
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rifampin (anti TB) and griseopholphin (an antifungal)- no evidence that antibiotics need back up
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How do you start to multi cycle on the nuvaring?
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Do three cycles of traditional use, then can leave in for 4 weeks and replace. If start to have breakthrough have a withdrawal bleed and then restart
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How do you multicycle the patch?
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not recommended
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What are the advantages of regulating menses?
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reduced menorrhagia, reduced menstrual related symptoms, reduced dysmenorrhea, reduced anemia
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What is the "quick start"?
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if rule out pregnancy then can start method immediately and more likely to continue- no additional irregular bleeding. good with new pts with pill, patch, ring
-Take first OC in presence of clinician on first day of visit |
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What are the 3 indications of Yaz?
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contraception, treatment of emotional and physical symptoms of PMDD, treatment of moderate acne
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What are combined emergency contraceptive pills?
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Ordinary OCP and combine doses (nausea!!)
-combines estrogen and progestin -first dose within 120 hrs of intercourse, second 12 hrs later. |
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What is progestin-only emergency contraception?
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Plan B- can take both pills at the same time, prevents ovulation but is NOT an abortive agent
First dose within 120 hours of intercourse, second dose 12 hrs later (or both at the same time) More effective than combined and less n/v |
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What type of IUD can be used as emergency contraception?
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copper, can be inserted up to 5 days after unprotected sex, more effective than pill. Copper has spermicidal action, causes inflammatory response at the lining
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What is the big problem with the patch?
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breast tenderness
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What did the media say was a greater risk with the patch
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veno thrombo embolism
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What hormonal method contains the least hormones?
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nuvaring, inhibits ovulation
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Summarize ovulation inhibition with NuvaRing
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During 3 weeks of continuous NuvaRind use
-largest follicles and estradiol levels occurred in first week -FSH concentrations were low -LH surge did not occur -Progesterone levels were low -ovulation completely inhibited |
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What is the non-contraceptive benefit of nuvaring?
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Decreased bacterial vaginosis, improves numbers of lactobacilli, supports healthy ecosystem
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What is the mechanism of action of progestin only pills?
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reduces activity of cillia in fallopian tubes (so increased ectopic pregnancy), otherwise similar to combo
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Who might you recomend progestin only pills to?
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migraine with aura, lactating women
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What is depo-provera?
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injection every 3 weeks, decreased teen pregnancy in 80's. Really puts ovary to sleep with delayed return to fertility. Might have irregular bleeding
-no evidence of decreased bone density but is restricted to 2 yrs, many orgs say this is silly |
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What is depo sub Q low?
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-indicated for contraception and endometriosis, can be self administered
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What is a complaint with progestin only pills?
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irregular bleeding
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What is the new black box warning for DMPA?
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bone loss
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What is implanon?
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progestin only, highly-effective, long term (3 plus years), immediately reversible
Rod superficially inserted under the skin 6-8 cm above the elbow crease at the inner side of the upper arm- between biceps and triceps |
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What is the mechanism of action of implanon?
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inhibits ovulation
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**What is the issue with implanon?**
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unpredictable bleeding, might be light or heavy, few of many days
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What does progesterone do?
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thickens cervical mucous
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Why are there so many unintended pregnancies?
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lack of education, lack of knowledge about options
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What are some misperceptions about the IUD?
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decreases fertility, causes disease, not safe, not effective
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Where on the cervix should the tenaculum be placed?
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at 11 and 1, have the pt cough when you do this (they don't feel or hear it)
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What are the 2 types of IUD and how long are they good for?
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-LNG- 5 yrs use
-Copper- 10 yrs use |
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Who can use IUDs?
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Nulliparous women can (myth is they can't), those who have had an ectopic pregnancy, do not need to be removed for PID treatment if it is responsive
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When if PID treatment would you have to pull an IUD?
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Pull IUD if PID is not responsive to treatment
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What is the mechanism of action of the copper T IUD?
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Primary is prevention of fertilization by reducing motility and viability of sperm and inhibiting development of ova. Inhibition of implantation is a secondary mechanism
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What is the mechanism of action of the LNG IUD?
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Fertilization inhibition by causing cervical mucus to thicken and inhibiting sperm motility and function, also inhibition of implantation
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What might a woman with a new LNG IUD expect?
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irregular spotting for up to 6 months, about 20% will be amenorrheic
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What is IUD efficacy comparable to?
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sterilization
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What is the relation between IUDs and PID?
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Behavior puts her at risk, not the IUD
PID incidence is similar to that of general population and risk is onlyd increased during the first month after insertion If have a preexisting STI at time of insertion then risk is increased |
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What if a woman gets pregnant with an IUD?
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If pregnancy is confirmed and can see string then recommend device be pulled. The IUD is extra-amniotic, no increase in birth defects for copper IUD
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Do IUDs impact fertility?
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no, but mirena might have a 4ish month delay
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Can IUDs be used by HIV positive women?
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yes, no increased risk of complications
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Can IUDs be used in nulligravid women?
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no evidence of increased infertility in nulliparous users, risk of PID and subsequent infertility is dependent on non IUD factors. Copper T labeling does not exclude nulliparous women
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*What are potential SE of IUD?*
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-During insertion: pain, cramping, vaso-vagal reactions
-First few days: light bleeding and mild cramping -First few months:intermenstrual bleeding and crampint -Copper T- heavier or prolonged bleeding -LNG- gradual decrease in menstrual flow |
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What are some non-contraceptive benefits of LNG IUD?
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-protection against endometrial cancer
-alternative to hysterectomy or endometrial ablation -treatment of heavy bleeding/ dysmenorrhea, pain -limited evidence in uterine fibroids, endometriosis, adenomyosis, endometrial hyperplasia or cancer |
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What are considerations in choice of contraceptive methods?
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effectiveness, side effects, convenience, duration of action and childbearing plans, patient choice, reversibility, non-contraceptive benefits, cost, privacy
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Who are appropriate candidates for copper T IUD?
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Women who don't want hormonal contraception or want contraception for less than 5 years
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Who are good candidates for LNG IUD?
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Women who request less menstrual flow and or experience dysmenorrhea, dysfunctional uterine bleeding
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Who are poor candidates for IUDs?
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-known or suspected pregnancy
-puerperal sepsis -immediate post septic abortion -unexplained vaginal bleeding -cervical or endometrial cancer -uterine fibroids that interfere with placement -uterine distortion (congenital or acquired) -current PID -current purulent, chlamydia or gonorrhea -known pelvic tuberculosis |
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When can a IUD be placed after abortion?
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-immediately after spontaneous or induced abortion, not after septic abortion
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When can IUD be placed postpartum?
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-Copper T within 48 hrs of delivery of after 4 weeks once the uterus is involuted
-LNG at 6 weeks postpartum |
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Can IUD be inserted in lactating women?
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-effectiveness is the same
-increased risk of perforation in pp lactating women -expulsion unchanged -decreased insertional pain |
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When is IUD use appropriate in adolescents?
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Appropriate for properly selected and counseled adolescents, follow-up and side-effect monitoring is important, encourage use of condoms with new patients
-routinely screen for c and g in women under 25 yo but don't hvae to rescreen before IUD |
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When might an IUD be used in an older woman?
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LNG for perimenopausal women, especially those with dysfunctional uterine bleeding, can be used off label as an adjunct to estrogen therapy for postmenopausal women
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What are IUD counseling topics?
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effectiveness, MOA, characteristics of method, including changes to menstrual flow, insertion and removal procedures, side effects and possible complications, instructions on follow-up, non-contraceptive benefits, use of condoms with new partners
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What are IUD side effects and complications?
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menstrual effects
-infection, perforation, expulsion, pregnancy, missing threads |
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What is IUD follow-up?
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3-6 weeks at clinician's discretion, routine well woman care. Return visit if possible expulsion or displacement, severe cramping or bleeding
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When should IUD be inserted?
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some say with menses so can be sure she isn't pregnant. Others say midcycle anytime to decrease expulsion but then must rule out pregnancy
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What are the steps for IUD insertion?
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1. pelvic for size and position of uterus. cleanse with betadine
2. apply tenaculum 3. sound the uterus 4. load device 5. place device 6. cut the threads |
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Where should the IUD be in the uterus?
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fundus
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Do perforations hurt?
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no, most are silent
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If a woman with IUD has severe bleeding or cramping 3-5 days after insertion, what might you expect?
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perforation of infection
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If a woman with IUD has irregular bleeding and/or pain every cycle, what might you expect?
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dislocation or perforation
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If a woman with IUD has fever, chilld, unusual vaginal discharge, what might you expect?
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infection
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What if she has pain during intercourse?
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infection, perforation, partial expulsion
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missed period, other signs of pregnancy, expulsion?
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pregnancy (uterine or ectopic)
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Shorter, longer or missing threads?
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partial or complete expulsion, perforation
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How might IUD expulsion present?
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partial or unnoticed expulsion may present as irregular bleeding and/or pregnancy.
risk of expulsion is related to provider's skill at fundal placement, age and parity or woman, time since insertion, timing of insertion |
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How would you manage heavy bleeding lasting > 3 months?
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examine for infection or fibroids, check for anemia, prescribe NSAIDs, remove if indicated. Also try doxycycline 100 mg BID for a week, might cut down inflammatory response
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How do you manage missing threads?
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probe for threads in cervical canal, prescribe back up contraception, get US or x-ray, remove copper IUD in abdomen
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How do you manage STI if has IUD?
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If symptoms improve within 72 hrs of treatment you do not need to pull the IUD- just treat the infection and counsel of STI prevention. If STI does not respond then must pull the IUD
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What is the rate of uterine perforation with IUD insertion?
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1/1,000. Risk doubled in first 12 weeks pp. can insert another device after next menses
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Pregnancy with IUD in situ- what do you do?
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determine the site of the pregnancy (IU of ectopic), remove IUD if threads available, removal decreases risk of SAB or premature delivery
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Name some disparities in unintended pregnancy
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Increased by 29% in women blown the FPL, decreased 20% among women 200% above the FPL
AA and hispanic women are a disproportionate share |
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What percent of teen pregnancies occur in the first 6 months after initiating intercourse?
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half, and 20% of teen pregnancies are in the first month
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Why is a planned pregnancy better?
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Better outcomes. Unplanned have increased risk of morbidity for women, increased risk of adverse effects on pregnancy, delayed prenatal care, increased unhealthy behaviors, delayed pregnancy dx
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Why do women experience unintended pregnancies?
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contraceptive failures (95% use birth control) or not using contraception (fear of side effects is huge), sexual assault, abuse, and coercion
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if doing the quick start method, how long must she use back-up?
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one week
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How much does plan B reduce pregnancy risk?
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by 89% if taken within 3 days
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What portion of unintended pregnancies are terminated each year?
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almost half, so that means 25% of all pregnancies are aborted
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What percentage of US women will have an abortion in their lifetime?
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43%
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What percentage of women have their abortion before 12 weeks? Why would they wait beyond 16 weeks?
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88.1%, wait because didn't realize they were pregnant (71%)
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What age of women has the most abortions?
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20-29 (56%)
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What are some of TN's abortion laws?
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parental consent or judicial bypass, no mandatory wait period, public funding available only for life endangerment, rape, incest
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What are the failure rates of medical and surgical abortions?
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Medical- 2-6%
Surgical 1% |
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What are the medical abortion meds?
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mifepristone/ misoprostol
methotrexate/misoprostol |
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What are the surgical abortion options?
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vacuum aspiration
dilation and curettage dilation and evacuation intact dilation and extraction |
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What is mifepristone?
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"Abortion pill"
-19-norsteroid with a high affinity for progesterone receptors, binds to progesterone receptors and blocks action of progesterone -decreases endometrial blood supply causing placental detachment -Used with misoprostol |
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What is misoprostol?
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prostaglandin analogue, accelerates process of expulsion, stimulates contractions and softens cervix
-used with mifepristone or methotrexate -this is cytotec |
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What is the FDA approved medication abortion regimen?
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Up to 49 days of pregnancy (7 weeks)
600 mg mifepristone on day 1, followed by 400 mcg misoprostol orally on day 3 -follow up on day 14 |
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Why might the alternative evidence based regimen for medical abortion be used over the FDA approved way?
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decreased time to expulsion with increased mifepristone, only 2 visits instead of three, cheaper, decreased side effects, more effective
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What is the alternative medical abortion regimen?
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200 mg mifepristone day 1 in clinic, 800mcg mifepristone day 2 or 3 at home, followed with misoprostol 24-48 hrs later. Follow up on day 4-8
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What is methotrexate?
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not approved for medication abortion- off label use,
antimiotic- inhibits DNA synthesis so stops cell division Used to treat ectopic cAn be used with misoprostol but this regimen takes more time to expel the pregnancy |
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Why do women choose a medical abortion? Surgical?
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Medical- less invasive, feels more natural, more in control, more private, can have a support person with them, more effective in very early pregnancy
Surgical- afraid of MAB at home, quicker, easier (no steps), want it over, less bleeding |
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With medical abortion, how long does it normally take to expel the preg?
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usually begins 1-2 hrs after taking cytotec at home, usually takes 4 hrs
-bleeding may last 9-16 days |
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What is vacuum aspiration abortion?
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Used in 90% of surgical abortions
-up to 13 weeks gestation -local cervical block -dilation of cervix -suction uterine contents |
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What is a dilation and curettage (D&C) abortion?
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-local cervical block
-dilation of cervix -curette inserted -uterine lining scraped to remove POC -some use combo of vacuum and d&C= suction D&C |
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What is a dilaction and evacuation (D&E) abortion?
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-2nd trimester, 13-20 weeks
-dilate cervix the night before with laminaria or cytotec -forceps with US to remove fetal parts -if done beyond 20 weeks MUST use digoxin to stop fetal heart first |
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What is intact dilation and extraction abortion (D&X)?
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"partial birth abortion"
-2nd trimester, 20-24+ weeks -cervix dilated over 2-3 days with with laminaria -forceps with US pull fetus out feet first, brain is suctioned. must stop fetal heart first |
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Why would a D&X be considered?
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hydrocephalus, decreased uterine tearing but increased injury
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What is a woman NOT at risk for with an early abortion?
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future SAB, ectopic, stillbirth, infant mortality, congenital anomalies, low birth weight, breast cA
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What are some complications of early abortion?
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hemorrhage, uterine perforation, cervical laceration, infection, incomplete AB, hematometra, asherman syndrome, DIC, death
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What is postabortal endometritis?
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1/100
S&S= sx within 2-4 days, CMT, pain, uterine tenderness, fever, purulent cervical/vaginal discharge, abdominal tenderness or rigidity, decreased bowel sounds, elevated WBC count -give antibiotics like rosefin or doxycycline |
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What is the relation of C. sordelli to abortion?
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very few deaths from this sepsis after medical abortion.
present with tachycardia, hypoTN, n/v/d less than 24 hours after takine MIFEPRISTONE |
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What are the S&S of retained POC?
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usually have S within one week including, charp pain, heavy bleeding, enlarged boggy uterus, heterogeneous pattern of endometrium on US, POS seen in os
-might be delayed up to one month -cous have persistent HCG or + preg test |
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How would you manage retained POC?
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cytotec, vacuum aspiration, pain meds, check hgb/hct
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What is hematometra?
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accumulation of blood and clots in the uterine cavity
usually occurs 5 minutes to several hours after surgical procedure, low midline pelvic pressure or pain, intermittent expulsion of clots or no bleeding at all, enlarged firm uterus, mild fever possible manage with vacuum aspiration, cytotec, methergine, pain meds |
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What is hemorrhage?
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blood loss of 250-500 cc or greater, do uterine massage, cervical pressure, methergine, pitocin
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What is uterine perforation?
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poking through the uterus, 1/500 abortions
excessive bleeding, sighting bowel, pain, hypovolemia might observe, ab, or transfer |
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What are cervical laterations?
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1/100
caused by tenaculum or calvarium, suspect this if heavy bleeding despite well contracted uterus. might observe, silver nitrate, or surgical repair |
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What is aggravated sexual battery?
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any pt 12 or younger who is sexually active, report
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What is statutory rape?
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pt from 13-17 and partner is 4 or more years older, reporting is encouraged
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What is child sexual abuse?
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minor pt is involved in a sexual relationship with an authority figure, repotr
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What is power rape?
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55%
goal is sexual conquest, overpowering -usually younger rapists that select their age or younger -might stalk, kidnap, rape repeatedly. -physical injury is uncommong repetitive |
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What is anger rape?
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-spontaneous and episodic
-attack might be triggered by sudden stress -offender wants to hurt and degrade, physical injury is common |
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What is sadistic rape?
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5%
-offender intentionally harms and mistreats his victim, they often do not survive -victim is random -jekyll and hyde personality |
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What is the most common emotion experienced by the victm?
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terror
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What are drug facilitated rape agents?
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-Rohypnol- a benzo, lasts up to 72 hrs
-GHB- quick working, clears quickly -Ketamine- fastest working and clearing All induce relaxation, drowsiness, difficulty with motor movements, anteriograde amnesia |
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How do you detect rape agents?
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***Detect rohypnol and ketamine in the urine, GHB in serum***
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What brain processes do rape victims report trouble with?
|
Those associated with the limbic system- holds traumatic memory
-arousal, sleep and rest, sexual response, and attachment |
